Table of Contents

Welcome Letter...... 2 Directions for Accessing Service...... 3 Financial Planning Benefits Real Estate Rebate...... 4 401K Retirement Plan...... 4 Health Benefits Vision...... 5 Dental...... 5 Hearing...... 6 24-Hour Nurse Hotline...... 7 Prescription Walk-In...... 7 Participating Pharmacies...... 8 Prescriptions Mail Order...... 9 Diabetic Supplies...... 10 Assistive Medical Devices...... 10 SAMPLETravel and Entertainment Benefits Car and RV Rental...... 11 Notes...... 12 Prescription Mail Order Form...... 14

DISCLOSURES FOR DISCOUNT PLAN BENEFITS

THIS PLAN IS NOT A HEALTH INSURANCE POLICY. This plan provides discounts at certain health care providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care service but will receive a discount from those health care providers who have contracted with this discount plan organization. It is the members responsibility to confirm with Member Services that a provider is an active participant of the program prior to seeing that provider. Discount Medical Provider Organization: MedNet Benefits Inc., 428 E. Thunderbird Road, #645, Phoenix, AZ 85022

Services may not be available in all states. Please call to verify availability in your home state.

Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees SAMPLE

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Directions for Accessing Services

The following pages will describe the individual benefits available to you as a member. There are two methods to access your benefits which will be indicated by the following icons:

INTERNET-BASED SERVICES:

www

This information is available on our website. 1. Connect to the Web through your Internet Service Provider (ISP). 2. In the “address” bar, enter the web address located on the back of your membership card. 3. Click on the “Member Login” button. 4. When prompted, enter your 9-digit membership number. 5. Enter your 4-digit “PIN” number. 6. Click the “Submit” button. 7. Click on the benefit you are interested in. PHONE-BASED SERVICES:

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Contact Member Services at 1-866-689-7283. Our Member Services agents are available to take your calls and assist you in accessing these benefits. In some cases you will be provided with a direct contact phone number and details to present in order to identify yourself as an active member. Procedure for Accessing Health Benefits LOCATING A HEALTH PROVIDER

1. Call 1-866-689-7283 to speak with one of our member services agents, who will provide you with participating health providers closest to the zip code that you live in. 2. Have your membership card handy as you will be asked for your member number. 3. Once we have found an eligible provider, you will be called back with the provider’s name, address and telephone number so that you can call his/her office to schedule your appointment. IT MAY TAKE OUR PROVIDER SCHEDULING DEPARTMENT UP TO 72 BUSINESS HOURS TO GET BACK TO YOU. SAMPLE4. If you wish to see a particular health provider that is not part of our network, we encourage you to call us with their name and phone number, and we will attempt to invite them to participate in our program. VISITING YOUR PROVIDER

1. Make sure that you take your membership card with you, (as you must show your membership card to be eligible for a discount), and some form of payment (cash, check or credit card). 2. You are obligated to pay for all health care service but will receive a discount from those health care providers who have contracted with this discount plan organization. 3. On occasion, the person at the provider’s office who pre-confirmed your discount may be away when you arrive. If the person you speak with at the provider’s office does not understand that you are eligible for a discount, have them call the Provider’s number on the back of your card while you are there. On rare occasions, the Provider may not honor your discount – if this happens, pay your bill and ask for a receipt. Then call Member Services and if you are eligible, we’ll arrange to forward to you the amount that you should have received as a discount. This refund service only applies to visits to physicians’s offices or dentist offices.

MedNet Benefits Inc. cannot guarantee or warrant that products, services and facilities are available in every geographic location. Our services and providers are subject to addition, deletion or change at any time and without prior notice to member.

Medical Discount Programs are provided to all NCEA Members in good standing. These benefits are purchased by the Association pursuant to a master group contract for such services issued in the State of Florida, and governed by the regulations of that State. The Association purchases these programs for its Members from a Discount Medical Plan Provider which is duly licensed, registered and fully compliant with all relevant regulations in the State of Florida.

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Financial Planning BENEFITS

REAL ESTATE REBATE )

Receive a rebate every time you buy or sell real estate.

Let us introduce you to a realtor from a well-known national, regional or local real estate organization. The realtors will be pre-screened and monitored by a leading real estate referral service. Save time, money and effort trying to find the realtor that might meet your specific needs.

As a NCE member, you will receive a cash rebate of $3.00 per each $1,000 increment in real estate transaction value. For example, $600 on a $200,000 purchase or sale (200,000/1,000 x $3 = $600), or $1,200 for two transactions at this value.

This service is available in states permitted by law.

401(K) RETIREMENT PLAN )

Having a 401(K) plan has never been easier!…or cheaper! Traditionally, a 401(k) was so expensive to establish and administer that it was not cost effective for a company under 50 employees to even consider it. The NCE Plan eliminates virtually all of the set up cost and all of the administration, while affording members ac- cess to investment vehicles traditionally limited to the largest company plans,. Our 401(K) plan is with Deutsche Asset Management & Scudder Investments, two of the largest and most respected financial institutions in the world. Each of our members have the choice to invest in several different investment options including “5 lifestyle choices” available for the convenience minded investor, and 300 different funds for the more savvy investor. SAMPLE

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Health BENEFITS

VISION )

Savings: 5% to 50%

As a current member, you and your family can save 5 to 50% at over 10,000 participating vision eye care locations nationwide. Discounted products and services include eyeglasses, contacts, prescription and non-prescription sunglasses, eye exams and corrective surgery. Our Vision Network includes ophthalmologists, optometrists, laser surgery centers, independent optical centers and national chain locations including EyeMasters, Pearle Vision, Sears Optical, JC Penney Optical, LensCrafters, Target Optical, Wal-Mart and many more.

Savings on Eyewear: Members save 5% to 50% on all frames, lenses and specialty items such as tints, scratch-resistant coatings, with or without ultraviolet protection. There is no limit on how often you and your family may use this service.

Eye Exams and Corrective Surgery: Our Network contracts with both ophthalmologists (medical doctors) and optometrists to provide you with savings on eye exams. Call Customer Service to find providers in your area. Selected ophthalmologists also provide corrective surgery, including LASIK and PRK surgery. Savings of up to 50% on physician and facility fees, eye exams and corrective surgery are included.

Mail-Order Contact Lenses: Replacement contact lenses can be ordered through our mail-order service. All major brands and types of contact lenses are available through this mail-order service. Members can call and receive price quotes for brands and types of lenses over the telephone.

TWO GUARANTEES: Satisfaction Guarantee – If you are not completely satisfied with your eyewear purchase from a participating provider for any reason, it may be returned within 30 days to the point of purchase for a complete refund. Low Price Guarantee – Once a purchase is made, if you find the identical eyewear at a lower advertised price, the difference will be cheerfully refunded.

SAMPLEDENTAL )

Savings: 5% to 50%*

Current members and their family can save an average of 5%-50% off of area dental procedures* when performed by a participating Dental Network dentist. With a network of tens of 1,000’s of credentialed dentists, chances are you’re sure to find a participating dentist regardless of where you live or work. Current members will save on routine dental services, such as cleaning, x-rays and fillings as well as crowns, root canals, dentures, oral surgery, orthodontics, periodontics and cosmetic dentistry where available.

Savings are received immediately at the time of service.

* Savings are based upon a comparison of national average negotiated network provider discounts. Actual savings will vary based upon procedure, geographic location, and the dentist’s dental discount.

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Health BENEFITS

HEARING PROGRAM )

Savings: 5% to 30% off on both services and hearing aids

Hearing Program Advantages • Discounted charges for diagnostic hearing evaluations performed by licensed audiologists • 20% off conventional hearing aids, or 10% off programmable/digital hearing aids • 20% off custom earmolds, repairs and related products (excluding batteries) • No charge for annual follow-up cleaning and check of hearing aids purchased through the program

Comprehensive Audiometry $49* Air & Bone Conduction Thresholds Word Recognition Measures *$59 in NY and CA (Additional charges may apply for children under 5 years of age)

Acoustic Immittance Testing $35 Tympanometry Acoustic Reflex Thresholds Acoustic Reflex Decay

Conventional Hearing Aids 20% Discount Prices not to exceed: In The Ear (ITE) $670 per hearing aid In The Canal (ITC) $770 per hearing aid Behind The Ear (BTE) $695 per hearing aid Completely In Canal (CIC) $1,175 per hearing aid All conventional circuitry is included in the above maximum discounted prices

SAMPLE • Programmable/Digital Hearing Aids 10% discount • Hearing Aid Evaluation - No Charge • Hearing Aid Dispensing - No Charge Providers may charge a maximum fee of $35 per returned hearing aid (plus earmold and/or manufacturer’s restocking fees, if any), subject to state law • Related Products, Custom Earmolds and Repairs 20% discount, excluding batteries • Annual Cleaning and Check - No Charge For any hearing aid purchased under the program

At your request, your audiologist will discuss noise exposure and your personal risk, including what you can do to avoid hearing loss.

NOTE: Pricing may vary. Amounts reflect national averages calculated from network provider claims data.

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Health BENEFITS

24-HOUR NURSE HOTLINE ) (Not Available in California)

Current members have 24-hour access to a Registered Nurse to answer any questions on family health issues, in English and Spanish. You can call anytime day or night, and qualified professionals are there to answer any questions you may have about any health issue. When you need help determining whether or not you or a family member needs to see a doctor, or when no one else is available to give you medical advice, our professional nurses are there to help. They can help with symptom assessment and can direct you to the best resource for your health care needs.

The 24-hour Nurse Hotline provides: • Peace of mind and convenience • Stress reduction • Cost-effective quality of care improvement • Reduction of unnecessary ER and physician visits • Ease of access to answers for health-related questions • Encouragement of early treatment • Help in preventing a small problem becoming a large one

Call 866-273-8850, 24 hours a day 7 days a week, to speak to a nurse. If you have an emergency, call 911.

PRESCRIPTION DRUG PROGRAM - WALK-IN www )

Savings: On an average, members will save 20% off Brand drugs and 55% off Generic drugs.

Discounts on All Prescription Drugs: Unlike most discount plans, your prescription plan provides discounts on all FDA-approved prescription drugs. There are no limited drug lists, gimmicks, or excuses.

National Savings at Over 55,000 Participating Pharmacies: Like to travel? We’ve got you covered. Your discount card is widely accepted at over 55,000 SAMPLEpharmacies across the United States. How Can I Receive My Savings: Simply present your membership card to the pharmacist at one of the more than 55,000 participating pharmacies. The pharmacist will enter your Member ID and Group ID (as provided on the card) into their system and the discount will be automatically calculated and applied to your transaction.

Unlimited Use: Members can use this service as often as needed. There are absolutely no restrictions or limits on usage.

The Pharmacy Web Tools will allow you to: • Locate participating pharmacies anywhere in the country • Get retail pharmacy drug pricing • Identify and price equivalent alternative drugs that may yield higher savings

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Health BENEFITS

• Access Health • Farm Fresh Pharmacy • Medic Discount Drug • Target Pharmacy • A W G Network • Farmer • Medic Pharmacy • The Pharmacy Coop. • A&H Stores, Inc. • Food City-K-Va-T • Medicine Center • Thrifty Payless • ACME Pharmacy • • The Medicine Shoppe • Tom Thumb Pharmacies • • • Mediserv • Tops • Amerisource Bergen • Four Star Drug • Med-X Drug • Ukrops Pharmacy • American Drug Stores • Pharmacy • Pharmacy • United Drugs • Arbor Drugs • Fred’s Stores • Metro Group • • Assured Pharmacies • Fruth Pharmacy • Minyard Pharmacy • USA Drug & Beauty • Atlas Drugs • Frys Food and Drug • Moore King Pharmacy • Vaden Corporation • Aurora Pharmacy • Genovese Drug Store • Morton Drug • Value Health Center • B & R Stores • , Inc. • Mullaney Pharmacy • Village Supermarkets • Balls Four • Giant of Maryland • Nash Finch • • Bartell Drugs • Giant Pharmacy • Neighborcare • • Big Bear-Prism • Foods • Oakwood Pharmacy • Walgreens • Big V Supermarkets • Hannaford Brothers • Pamida Pharmacy • Wakefern Food • Bi-Lo Pharmacy • Happy Harrys Drugs • Park Nicollet • Wayne Oakland Pharm. • Bi-Mart Drugs • • Stores • Weis Pharmacies • BJ`S Wholesale Club • • • Winn-Dixie • Brookshire Bros • Hartig Drug Store • Perlmart • Yokes Pharmacy • Brookshire Grocery • Heartland Pharmacy • Pharmacy Express • Zallie Supermarkets • Brown and Cole • Hi-School Pharmacy • Phar-Mor • Brunos Pharmacy • Stores • Polks Discount Drugs • Buehler Foods • Hy-Vee Pharmacy • Price Cutter Pharm. Please note: • Buehler Pharmacy • IHC Pharmacy • Price Less Drugs • Carrs Quality Center • IHS Infusion Services • Prof. Specialized This listing • CBC Prof. Pharmacy • Markets • Professional Village is subject to • City Market • Inserra Supermarkets • change at any • Coborns Pharmacy • Integrity Healthcare • Quality Food Centers time. • Community Pharmacies • JH Harvey • • • JSA Healthcare • Raleys Drug Center • CVS Pharmacy • Kash N Karry • Grocery • D & W Food Centers • Kerr Drugs, Inc. • Food & Drug • Dahls Pharmacy • Keystone Pharmacy • Revco Discount Drugs SAMPLE• Dayton • Grocery • Rinderers Drug • Dierbergs • Pharmacy • Rite Aid • Dillon Pharmacy • Kinney Drugs • Ritzman Pharmacy • Discount Drug Mart • Kliens Super Market • Ronetco Stores • Discount Emporium • Klingensmiths Drug • RXD Pharmacy • Docs Drugs • K-mart • Safescript Pharmacy • Dominicks Pharmacy • Knight Drugs • Safeway Pharmacy • Drug Emporium • Kohlls Pharmacy and • Save Mart Pharmacy • Drug Fair-Community Homecare • Sav-Mor Drug Stores • Drug World Pharmacies • Kopp Drug • Pharmacy • Duane Reade • • Scolaris Food & Drug • Eagle Food • Laurenti • Seaway Food • Eaton Apothecary • Leader • Sedells Pharmacy • Eckerd Pharmacy • Lifechek • Shaws Supermarkets • Ensign Pharmacy • Longs Drug Store • Shopko Pharmacy • Fagen Pharmacy • Louis and Clark Drug • Shoppers Food • Fairview Health Sevices • M and H Drugs • Shoppers Pharmacy • Family Care Network • Marcs Pharmacy • Shoprite Pharmacy • Family Care Plus • Marsh Drug Store • Smiths Pharmacy • Family Drug Store • Marshfield Pharmacy • Snyder Drug Stores • Pharmacy • Martins Super Mkts • Stop and Shop • Family Pharmacy • Maxi Drug • Super D Drugs • Familymeds • Med-Fast Pharmacy • Supervalu Pharmacies 8

Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Health BENEFITS

PRESCRIPTION DRUG - MAIL ORDER )

Savings: 5% to 60%

This mail order Prescription Drug Discount benefit, provided through Caremark, allows you to maximize your savings on prescription drugs ordered in 30- day to 90-day supplies. You can save 5% to 60% on your maintenance medications. Mail-order prescriptions will be shipped directly to your home at no additional charge.

Typically, the mail order Pharmacy provides the highest level of benefit for those members that require long-term medication. This benefit is not designed for prescriptions that you need immediately.

If you are currently taking medications for a chronic illness (maintenance medication), or if your doctor prescribes such medication in the future, you may use this service for home delivery.

Lower Cost Generics You can also save money by using less expensive brands and generic drugs. Less expensive generics meet the same safety and effectiveness standards. Ask your doctor if a less expensive or generic drug can be utilized. Caremark will dispense a generic equivalent whenever possible unless instructed otherwise by your doctor. HOW TO USE THIS SERVICE:

In order to get started, Caremark requires you to complete a patient profile and order form. This form is located at the back of this manual. We suggest that you make a photocopy of this form and keep the original intact in case you need it for other maintenance medications in the future.

When you have completed both sides of this form, attach the hard-copy prescription written by your doctor to the completed forms and mail to Caremark. If you need to start your medicine right away, ask your doctor to write two prescriptions – one for a smaller quantity (less than a 30-day supply) to be filled at one of our local network pharmacies, and one prescription for between a 30-day and 90-day supply to be filled by Caremark.

Order Processing and Shipping Caremark processes all complete orders within 48 hours. It is best to order 14 days in advance of running out of your current supply. Orders missing information (including the hard-copy prescriptions) will require additional processing time.

Payment is made using any major credit card, checks or money orders. Prescription drug orders are shipped at no charge via First Class Mail. Additional fees may SAMPLEapply for other shipping options.

Caremark will NOT honor any requests to cancel or return orders once they have been placed.

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Health BENEFITS

DIABETIC SUPPLIES ) Savings: 5% to 40%

Our provider is a nationwide provider of direct-to-consumer diabetes supplies. The Company provides diabetes products, disease management and educational services to help patients lead healthier and more productive lives. They provide an easy-to-use, cost effective and convenient way for patients to obtain diabetes supplies and medications.

Our provider’s products includes blood glucose meters, test strips and ancillary supplies, insulin pumps and supplies, therapeutic shoes and orthopedic inserts and diabetes maintenance medications. The company has contracted with suppliers to develop customized formularies for supplies and medications, providing flexible choices and bottom line savings.

The company provides the highest quality of products, carrying such brands as Johnson & Johnson, Roche, Bayer and Abbott. The medications provided will include insulin from Lilly and NovoNordisk, and oral diabetic medications from Bristol Myers Squibb, Glaxo Smithkline and Pfizer. They also dispense generic diabetes medications that have proven to be equivalent to the name brand product.

Mail-Order Convenience

• Products are delivered direct to member’s home at no additional cost. • No waiting in pharmacy lines. • 90-day supply of medications and supplies. • No insurance forms to complete. • Choice of products. • Certified Diabetes Educators to assist patients. HOW TO USE THIS SERVICE:

Simply call their toll free 800 number and identify yourself as a participating member and provide the customer service person with code number 1444.

To order call 800-505-1627 Code 1444

MEDICAL-HEALTH ASSISTIVE DEVICES ) www SAMPLESavings: 5% to 50% Our provider is a resource for assistive devices which can help people maintain their independence. Due to limiting physical conditions, many people find themselves less able to cope with everyday tasks and hobbies. Our provider supplies products to help you live “Life without Limitations.” Assistive devices aid in the essentials of daily living: bathing, dressing, eating, using the toilet, walking and transferring into or out of a bed, chair, bathtub, car, etc. And let’s not forget recreation, low vision and hobbies. The goal of our provider is to give you friendly, prompt, personalized service. Most orders placed before 2:00 PM Mountain Standard Time are shipped the same day (Monday through Friday). Your membership and PIN numbers found on your membership card will give you access through our website to shop and purchase hundreds of products at “member-only” prices, or you can call our toll-free number for shopping assistance. If the item that you’re looking for is not carried by our provider, the representative will try to find it for you.

Your satisfaction is guaranteed. Refunds and replacements are cheerfully extended on all returns within 30 days of your order. A call for a return authorization number is all that is needed. (Not Returnable: items that are feeding and hygiene products which have been removed from their packaging.) Of course, all defective items are returnable.

Most items are shipped UPS ground. Shipments should reach you in two to seven days, depending on your location.

Over 10,000 Products Some examples: • Aids for Daily Living for Kitchen, Bath, Grooming • Mobility Equipment and Accessories • Specialty Garments • Durable Medical Equipment • Rehab and Exercise Equipment (land and aqua) • Aqua Therapy Tubs and Decorative Plumbing • Urological and Ostomy Accessories • Home Automation/Modification • Ergonomic and Medical Products for the Workplace • Retrofitting Products/Construction Solutions • Splints and Braces • Innovative Product Solutions and Gift Ideas

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Travel and Entertainment BENEFITS

ALAMO RENT-A-CAR )

Savings up to 20% · Year-round membership discounts of up to 20% at more than 1,000 participating locations throughout the United States, Canada, Europe, Mexico, Latin America and the Caribbean · Unlimited Mileage · A wide selection of quality vehicles including luxury cars, convertibles, SUVs and minivans

Producer code # # 7013112

NATIONAL CAR RENTAL )

National Car Rental is one of the nation’s largest car rental companies serving the most popular domestic and international travel destinations by providing quality vehicles and service to business and leisure customers. National Car Rental operates in over 3,000 locations throughout the United States, Canada, Europe, Mexico, Latin America, the Caribbean, Asian-Pacific, Africa and Australia.

Members will receive a capped corporate rate when they quote Producer Code: #3715169

Emerald Club Members receive complimentary membership in the elite Emerald Club which is designed to get you in, out and on your way faster than ever before.

Producer code: # 3715169

RV RENTALS )

With 131 motorhome rental centers in the United States & Canada, Cruise America is one America’s largest motorhome rental centers. Cruise America’s Freedom Motorhome Rental Rates include Peace of Mind protection coverage. Just a simple $500 damage deductible per occurrence and up to $1,000,000 in Supplemental Liability Insurance are included at no charge. Other RV rental companies may charge up to $26 per day for similar coverage. NCE Members receive a further 10% SAMPLEdiscount when they quote Discount Code: MED10.

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Notes

SAMPLE

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees Notes

SAMPLE

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Benefits provided through This package of benefits is not a substitute for comprehensive health insurance. membership in The National Congress of Employees For information, visit our Web site at www.caremark.com ´,q¶4I¨ or call the number on your prescription card.

Mail Service Order Form Instructions: Please PRINT in CAPITAL letters using BLACK ink only.Fill in the applicable ovals completely ( ). Mail this completed form,the doctor’s signed prescription(s),and your payment to 13598 Rev. 9/04 Caremark in the envelope provided or to the address on the bottom of this form. XXXXX-XXXX Plan Participant Information/ 1 Health History Primary Plan Participant Identification Number (refer to your prescription card) Date Form Submitted:

Primary Plan Participant Name (Last Name) (First Name) (MI)

Delivery Address (if you select 2nd Day or Next Day shipping,fill in a street address,not a P.O.Box)

City State Zip

Phone Number () Above delivery address is: For this order only For this and all future orders E-mail Address,if available

Providing your e-mail address and phone number authorizes us to contact you about your Caremark account or our services.This information will not be shared with any outside party.If other household members also use this e-mail address,they may be able to access your health information. Mark all allergies or conditions that apply to you,your spouse or covered dependents that have

a prescription submitted with this form by completely filling in the oval below that description. below) (list SAMPLEContact your doctor if you are unsure about any health conditions.This information will not be required on future order forms unless there has been a change in health status. Birthdate Epilepsy Other Conditions (list below) Glaucoma No Known Allergies Penicillin Allergy Sulfa Allergy Other Allergies Diabetes Thyroid Heart Condition Pressure Blood High Ulcers Primary Plan Participant ‘s First Name MM D D Y Y Y Y Male/Female (M / F)

Spouse’s First Name

Other Dependent’s First Name

Other Dependent’s First Name

Please write first name and then list “other allergies”and/or “other conditions”referenced above

List any non-prescription medicines that you take on a regular basis or prescription medicines that you obtain without your Caremark prescription plan:

Caremark • P.O.Box 830070 • Birmingham,AL 35283-0070 New Prescription Enclose original doctor-signed prescription(s) and payment with this form. Ask your doctor to 2 Information write your mail service prescription for the maximum supply allowed by your plan (if appropriate).

Prescriptions are for: Primary Spouse of Other Dependent(s) Plan Participant Plan Participant Total number of medicines in this order: Doctor Name (Last Name) (First Name)

Doctor Phone Number ()

Do not contact my doctor for approval to change my prescription to a preferred medicine. Your benefit plan sponsor may consider certain medicines to be “non-preferred”or ”non-formulary”.Usually, this means that there is another medicine that may work the same way and do the same thing, but may be less expensive. As a service to you, we may contact your doctor for approval to dispense the alternate medicine,if one exists.If you mark this oval,Caremark will not contact your doctor for approval to change your medicine. Mark here if you want your mail service materials printed in Spanish. Generic Medicines:We want to provide you with high quality medicines at the best possible price. In order to do this,we will substitute generic medicines for brand name products whenever possible.No change to a generic will be made if your doctor specifies that a brand name medicine should be dispensed.If you do NOT want us to substitute a generic,please list the medicine name(s) in the comments section below that you would like dispensed as brand name only. Comments:

Shipping/ Your order will be shipped standard delivery at no charge.Please allow 14 2nd Business 3 Payment days from the date you mail your order for delivery of your medicine. If Day = $10 (per order) Information you prefer expedited delivery, mark the appropriate oval. Expedited Next Business shipping only affects shipping time,not processing time of your order. Day = $15 (per order) All medicines in this order will be sent in the same package to the address provided. If a family member does not SAMPLEwant his or her medicine sent in the same package as that of other family members, he or she should complete a separate order form. Payment,when applicable,is due with each order and may be made by credit card,check or money order. Payment by credit card is preferred. If paying by check, make the check payable to Caremark. Please write your Plan Participant identification number on your check. There is a $20 returned check charge. Do not send cash. Orders received without payment may result in a delay of processing.Any outstanding balances will be the responsibility of the primary insured. If you have questions about your payment amount, call the number on your prescription card or the phone number printed on the front of this form,if available.

Credit Card (provide information below) Payment by Check or Money Order MasterCard Visa Discover American Express Exp.Date Credit Card # (MM-YYYY)

Credit Cardholder Signature This credit card will be billed for medicine costs,expedited shipping (if applicable) and any outstanding balances.It will also be billed for all future orders,unless you provide a different form of payment. By returning this form to Caremark, you consent to the use and release of your health information and that of your covered dependents (if you are their guardian or authorized representative) to your health plans and healthcare providers/agents for health benefits management. SAMPLE